Uninsured Care Programs For HIV/AIDS
Documentation Guide |
Category | Documents |
Residency
The address must match the home address written in the application. | ___ Rent receipt
___ Lease
___ Driver’s license
___ Fuel/utility bill
___ Voter registration card
Roomer/Boarder: In cases where an applicant pays room/board to another individual and does not have bills in their own name, obtain a letter of residency from that person stating the client lives with them AND proof of the letter writer’s New York State residency. The applicant does not have to disclose HIV status to that person, and UCP does not have to know the income of that person.
No address/Homeless: If the applicant has no address, is living in a shelter or is transient (for example, sleeping from place-to-place with different family members or friends), a case manager or social worker can write a letter on agency stationary stating that the applicant is being seen in the clinic on an on-going basis. The letter should also tell the UCP where to mail the ADAP card and other correspondence. UCP can also accept a medical clinic face sheet listing the applicant’s name and address. If the program cannot contact the applicant, services may not be provided. |
Medical Criteria | ___ Proof of HIV status for ADAP, ADAP Plus, Home Care, APIC
___ Proof of negative HIV test result and be at risk of acquiring HIV infection for PrEP-AP
___ DOH-3608, found at https://www.health.ny.gov/forms/doh-3608.pdf signed by a licensed medical professional (by MD, PA, NP ) verifying HIV-infection and indicating the applicant’s medical status. |
Income
Include income documentation for each member of the household for whom the applicant has a legally responsible relationship (spouse or parent to child) | Wages & Salary
___ Paycheck stubs for the previous 30 days, must include the year to date salary, hours worked and the period the stub covers.
___ Notarized letter from employer on company letterhead, signed and dated, showing gross pay for the last 30 calendar days and a copy of previous’ year income tax return.
Self-Employment
___ Current signed and dated income tax return and all schedules
___ Records of earnings and expenses/business records
Veteran’s Benefits
___ Award letter
___ Benefit check stub
___ Correspondence from Veterans Affairs
Military Pay
___ Award letter
___ Check stub
Child Support/Alimony
___ Letter from person providing support
___ Letter from court
___ Child support/alimony check stubs
___ Copy of New York Child Support debit with printout
Unemployment Benefits
___ Award letter/certificate
___ Monthly benefit statement from NYS Department of Labor
___ Printout of recipient’s account information from the NYS Department of Labor’s website
___ Copy of direct payment card with printout
___ Correspondence from the NYS Department of Labor
Social Security
___ Award letter/certificate
___ Annual benefit statement
___ Correspondence from Social Security Administration
Worker’s Compensation
___ Award letter
Private Pensions/Annuities
___ Statement from pension/annuity
Interest/Dividends/Royalties
___ Recent statement from bank, credit union or financial institution
___ Letter from broker
___ Letter from agent
___ 1099 or tax return, if not other document is available
Support from other family members
___ Signed statement or letter from family member |
Proof of Health Insurance/Medicaid
If applicant has other insurance | ___ Copy of the front and back of the insurance cards
___ Copy of the front and back of Medicare/Medicare Advantage cards
___ Medicaid case number, if applicant has Medicaid
___ Amount of Medicaid spenddown, if on spenddown |
For APIC Applicants | ___ A statement of health insurance benefits, specifying the type of insurance program
___ A copy of front and back of insurance card(s)
___ A copy of the most recent statement or bill containing the applicant’s policy and group number, payment due date, payment amount and frequency of payments made by the participant
___ For Employer-provided coverage: A copy of a recent pay stub showing employee contribution
___ For COBRA Coverage: A copy of the COBRA paperwork stating when and where payment is due
___ For Coverage from the New York State of Health: a copy of the enrollment receipt or the most recent invoice for the coverage
___ For Medicare Part D, Medicare Advantage, Medicare Supplemental coverage: A copy front and back of the Medicare cards, as well as coverage cards, and a copy of the most recent statement or bill |
